Subjective: SUBJNOHEADERBEGIN|1|||0||MR_COMSUM^``^#`BEGIN^``^#`Subjective^``^#`2^``^#`2183268.691708^``^#`0^``^#`1^``^#`MR_COMSUM^``^#`BEGIN^``^#`Subjective^``^#`2^``^#`2183268.691708^``^#`0^``^#`1^``^#` SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Subjective^``^#`2^``^#`2183268.691708^``^#`0^``^#`1^``^#`SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Subjective^``^#`2^``^#`2183268.691708^``^#`0^``^#`1^``^#` SUBJNOHEADERBEGIN|1|||0||NAME|0|||0||Devin SlickNAME|0|||0||is a AGE|0|||0||34 y.o.AGE|0|||0||SEX|0|||0||maleSEX|0|||0||who is seen today for CCN|1|||0||New Patient (Establish Care)CCN|1|||0||History of Present Illness BLOCKBEGIN|SFHPI|BLOCKBEGIN|SFHPI|49000__49156_BEGIN49000__49156_BEGINThis is a very pleasant 34 year old gentleman here today for a general medical evaluation. He states that he has not seen a physician in greater than 10 years. He has no significant past medical history. He is in need of a Tdap. He states that he has a few chronic aches and that he would like to se eif there is anything he can do for these. Primarily is an old ankle injury. 49000__49156_END49000__49156_END BLOCKEND|SFHPI|BLOCKEND|SFHPI|Allergies Patient ALGP|1|||0||has No Known Allergies.ALGP|1|||0|| Medical History Patient PMHPNN|1|||0||has a past medical history of Patient denies medical problems.PMHPNN|1|||0|| Surgical History Patient PSHP|1|||0||has a past surgical history that includes Tonsillectomy and adenoidectomy. PSHP|1|||0||" Family History FAMHX|1|||0||Family History Problem Relation Age of Onset ? Hypertension Mother ? Factor V Leiden deficiency Mother ? Diabetes Father ? Factor V Leiden deficiency Sister ? Factor V Leiden deficiency Brother FAMHX|1|||0||Social History Patient SOCHXP|1|||0||reports that he has never smoked. He has never been exposed to tobacco smoke. He has never used smokeless tobacco. He reports current alcohol use of about 2.5 standard drinks per week. He reports that he does not use drugs.SOCHXP|1|||0||Review of Systems BLOCKBEGIN|HTPNROSBYAGE|BLOCKBEGIN|HTPNROSBYAGE|1000423__75002_BEGIN1000423__75002_BEGIN1000423__75002_END1000423__75002_ENDReview of Systems 1000423__1000431_BEGIN1000423__1000431_BEGIN Constitutional: Negative for activity change, appetite change, chills, diaphoresis, fatigue, fever, general weakness, hot flashes, night sweats, unexpected weight change, chronic pain and excessive daytime sleepiness. 1000423__1000431_END 1000423__1000431_END1000423__75641_BEGIN1000423__75641_BEGIN Endocrine: Negative for cold intolerance, heat intolerance, polydipsia, polyphagia and polyuria. 1000423__75641_END1000423__75641_END1000423__1016313_BEGIN1000423__1016313_BEGIN Allergic/Immunologic: Negative for environmental allergies, food allergies and immunocompromised state. 1000423__1016313_END1000423__1016313_END1000423__1016315_BEGIN 1000423__1016315_BEGIN Hematological/Lymphatic: Negative for adenopathy and easy bleeding. 1000423__1016315_END1000423__1016315_END 1000423__1000461_BEGIN1000423__1000461_BEGIN Psychiatric/Behavioral: Negative for agitation, behavioral problems, confusion, hallucinations, self-injury, sleeping problems and suicidal thoughts. The patient is not nervous/anxious and is not hyperactive. 1000423__1000461_END1000423__1000461_END1000423__1000427_BEGIN 1000423__1000427_BEGIN HENT: Negative for choking, congestion, dental problem, ear discharge, ear pain, facial swelling, hearing loss, mouth sores, neck stiffness, nosebleeds, postnasal drip, rhinorrhea, sinus pain, sneezing, snoring, sore throat, tinnitus and vertigo. 1000423__1000427_END1000423__1000427_END1000423__1016321_BEGIN1000423__1016321_BEGIN Eyes: Negative for photophobia, pain, discharge, redness, itching and visual disturbance. 1000423__1016321_END1000423__1016321_END1000423__1000459_BEGIN1000423__1000459_BEGIN Neurological: Negative for balance issues, coordination issues, dizziness, facial asymmetry, seizures, syncope, tremors, speech difficulty, light-headedness, numbness and headaches. 1000423__1000459_END1000423__1000459_END 1000423__1016317_BEGIN1000423__1016317_BEGIN Respiratory: Negative for chest tightness, cough, hemoptysis, observed breathing pauses during sleep, sputum, shortness of breath and wheezing. 1000423__1016317_END1000423__1016317_END1000423__1016323_BEGIN 1000423__1016323_BEGIN Cardiovascular: Negative for chest pain, dyspnea on exertion, palpitations, orthopnea, claudication, PND, cyanosis, near-syncope and lower extremity swelling. 1000423__1016323_END1000423__1016323_END1000423__1000429_BEGIN 1000423__1000429_BEGIN Skin: Positive for skin lesions and subcutaneous nodules . Negative for abnormal color change, dry skin, flushing, hair changes, itching, nail changes, rash and wound healing issues. 1000423__1000429_END1000423__1000429_END1000423__1016319_BEGIN1000423__1016319_BEGIN Musculoskeletal: Negative for arthralgias, back pain, gait issues, joint swelling, myalgias and neck pain. 1000423__1016319_END1000423__1016319_END1000423__1016326_BEGIN1000423__1016326_BEGIN Breast: Negative for breast lump.1000423__1016326_END1000423__1016326_END1000423__1000433_BEGIN1000423__1000433_BEGIN Gastrointestinal: Negative for abdominal pain, anorexic behavior, bloating, fecal incontinence, bright red hematemesis, coffee ground emesis, change in bowel habit, constipation, diarrhea, early satiety, fecal incontinence, flatus, heartburn, nausea, rectal pain, rectal bleeding, trouble swallowing and vomiting. 1000423__1000433_END1000423__1000433_END1000423__1000424_BEGIN1000423__1000424_BEGIN Genitourinary: Negative for bladder incontinence, decreased urine volume, dysuria, enuresis, flank pain, frequency, hematuria, nocturia, urinary retention, urgency, decreased libido, dyspareunia, genital lesion, penile discharge, sexual difficulties, scrotal swelling and testicular pain. 1000423__1000424_END1000423__1000424_ENDBLOCKEND|HTPNROSBYAGE|BLOCKEND|HTPNROSBYAGE| SUBJECTIVEEND|1|||0||MR_COMSUM^``^#`END^``^#`Subjective^``^#`0^``^#`2183268.702628^``^#`0^``^#`1^``^#`MR_COMSUM^``^#`END^``^#`Subjective^``^#`0^``^#`2183268.702628^``^#`0^``^#`1^``^#` SUBJECTIVEEND|1|||0||Objective: OBJNOHEADERBEGIN|1|||0||MR_COMSUM^``^#`BEGIN^``^#`Objective^``^#`2^``^#`2183268.703981^``^#`0^``^#`2^``^#`MR_COMSUM^``^#`BEGIN^``^#`Objective^``^#`2^``^#`2183268.703981^``^#`0^``^#`2^``^#` SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Objective^``^#`2^``^#`2183268.703981^``^#`0^``^#`2^``^#`SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Objective^``^#`2^``^#`2183268.703981^``^#`0^``^#`2^``^#` OBJNOHEADERBEGIN|1|||0||VITALSFULL|1|||0|| Vitals Recorded in This Encounter 1/6/2023 1340 BP: 120/84 Pulse: 64 Resp: 16 Temp: 97.8 F (36.6 C) Temp src: Temporal Weight: 98.9 kg (218 lb) Height: 182 cm (71.65") BMI (Calculated): 29.9 VITALSFULL|1|||0||BMI|1|||0||Body mass index is 29.85 kg/m.BMI|1|||0||BLOCKBEGIN|HTPNPHYEXAMBYAGE|BLOCKBEGIN|HTPNPHYEXAMBYAGE|Physical Exam 1011192__1011193_BEGIN1011192__1011193_BEGIN Constitutional: He appears well-developed and well-nourished. He does not appear ill. No distress. 1011192__1011193_END1011192__1011193_END1011192__1000446_BEGIN1011192__1000446_BEGIN HENT: Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane, external ear and ear canal normal. No impacted cerumen present. Tympanic membrane is not erythematous and not bulging. Left Ear: Tympanic membrane, external ear and ear canal normal. No impacted cerumen present. Tympanic membrane is not erythematous and not bulging. Nose: Nose normal. No rhinorrhea, nasal discharge or congestion. Mouth/Throat: Oropharynx is clear and moist and oropharynx normal. Dentition is normal. No dental caries. No oropharyngeal exudate or posterior oropharyngeal erythema. No tonsillar exudate. Pharynx is normal. 1011192__1000446_END1011192__1000446_END1011192__75105_BEGIN1011192__75105_BEGIN Eyes: Pupils are equal, round, and reactive to light. Conjunctivae, EOM and lids are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. 1011192__75105_END1011192__75105_END1011192__1016336_BEGIN1011192__1016336_BEGIN Neck: Normal range of motion and neck supple. No JVD present. Carotid bruit is not present. No tracheal deviation present. No thyromegaly present. 1011192__1016336_END 1011192__1016336_END1011192__1000604_BEGIN1011192__1000604_BEGIN Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard.1011192__1000604_END1011192__1000604_END1011192__1017310_BEGIN1011192__1017310_BEGIN Pulmonary/Chest: Effort normal and breath sounds normal. No stridor. No respiratory distress. He has no wheezes. He has no rhonchi. He has no rales. He exhibits no tenderness. 1011192__1017310_END1011192__1017310_END 1011192__1018171_BEGIN1011192__1018171_BEGIN Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is no abdominal tenderness. There is no rebound, no guarding, no right CVA tenderness and no left CVA tenderness. No hernia. 1011192__1018171_END 1011192__1018171_END1011192__1000417_BEGIN1011192__1000417_BEGIN Genitourinary: Rectal exam declined Penis normal. No penile tenderness. 1011192__1000417_END1011192__1000417_END1011192__1011198_BEGIN1011192__1011198_BEGIN Musculoskeletal: Normal range of motion. No tenderness, deformity or edema. Right lower leg: No edema present. Left lower leg: No edema present.1011192__1011198_END1011192__1011198_END1011192__1000235_BEGIN1011192__1000235_BEGIN1011192__1000235_END1011192__1000235_END 1011192__75383_BEGIN1011192__75383_BEGIN Lymphadenopathy: He has no cervical adenopathy. 1011192__75383_END1011192__75383_END1011192__1018174_BEGIN1011192__1018174_BEGIN Neurological: He is alert and oriented to person, place, and time. He has normal reflexes. He is not disoriented. He displays no weakness and normal reflexes. No cranial nerve deficit or sensory deficit. He exhibits normal muscle tone. Coordination and gait normal. 1011192__1018174_END1011192__1018174_END1011192__1000420_BEGIN1011192__1000420_BEGIN Skin: Skin is warm and dry. No bruising, no lesion and no rash noted. He is not diaphoretic. No erythema. No jaundice or pallor. 1011192__1000420_END1011192__1000420_END1011192__75442_BEGIN1011192__75442_BEGIN Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal. 1011192__75442_END1011192__75442_END1011192__75063_BEGIN1011192__75063_BEGIN Nursing note and vitals reviewed.1011192__75063_END1011192__75063_END BLOCKEND|HTPNPHYEXAMBYAGE|BLOCKEND|HTPNPHYEXAMBYAGE|BLOCKBEGIN|ASTHMAP2|BLOCKBEGIN|ASTHMAP2|.BLOCKEND|ASTHMAP2|BLOCKEND|ASTHMAP2|OBJECTIVEEND|1|||0||MR_COMSUM^``^#`END^``^#`Objective^``^#`0^``^#`2183268.736414^``^#`0^``^#`2^``^#`MR_COMSUM^``^#`END^``^#`Objective^``^#`0^``^#`2183268.736414^``^#`0^``^#`2^``^#` OBJECTIVEEND|1|||0||Assessment & Plan: ASSESSNOHEADERBEGIN|1|||0||MR_COMSUM^``^#`BEGIN^``^#`Assessment^``^#`2^``^#`2183268.737605^``^#`0^``^#`3^``^#`MR_COMSUM^``^#`BEGIN^``^#`Assessment^``^#`2^``^#`2183268.737605^``^#`0^``^#`3^``^#` SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Assessment^``^#`2^``^#`2183268.737605^``^#`0^``^#`3^``^#`SECTION_BOOKMARK_END^``^#`MR_COMSUM^``^#`BEGIN^``^#`Assessment^``^#`2^``^#`2183268.737605^``^#`0^``^#`3^``^#` ASSESSNOHEADERBEGIN|1|||0||ASSESSPLAN1|1|||0||Routine general medical examination at a health care facility Assessment & Plan: ASSESSMENT: The patient's condition is new . PLAN: 1. Patient is doing well. Preventive care updated. 2. Patient Counseling: --Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance, sufficient intake of fresh fruits, vegetables, fiber, calcium, iron, and 1 mg of folate supplement per day (for females capable of pregnancy). --Discussed the issue of estrogen replacement, calcium supplement, and the daily use of baby aspirin. --Exercise: Stressed the importance of regular exercise. --Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use; driving or other dangerous activities under the influence; availability of treatment for abuse. --Sexuality: Discussed sexually transmitted diseases, partner selection, use of condoms, avoidance of unintended pregnancy and contraceptive alternatives. --Injury prevention: Discussed safety belts, safety helmets, smoke detector, smoking near bedding or upholstery. --Dental health: Discussed importance of regular tooth brushing, flossing, and dental visits. --Immunizations reviewed. --Discussed benefits of screening colonoscopy. --After hours service discussed with patient 3. Discussed the patient's BMI with him. The BMI is above average; BMI management plan is completed 4. Follow up in one year Orders: - CBC with Differential - Comprehensive Metabolic Panel - Lipid Panel - Thyroid Stimulating Hormone Need for vaccination - Tdap (7 years and older) IM ASSESSPLAN1|1|||0||